What is Metro Health doing about Heart Failure?
Heart failure is the leading cause of hospitalization among people with Medicare. One in five Medicare patients with heart failure are readmitted within 30 days of initial treatment. Overall, heart failure cases cost this country over $17 billion each year.
For these, and other reasons, national hospital rating systems pay a great deal of attention to how well organizations treat heart failure. By improving our heart failure performance, Metro Health can improve our national rankings, save money, and keep patients well and out of the hospital!
At Metro Health Hospital and our neighborhood outpatient centers we use a multi-disciplinary approach to improve our readmission and mortality rates. Our team includes clinicians from both inpatient and outpatient settings and from several departments. Through the LEAN process and the Blue Cross Blue Shield of Michigan Better Outcomes for Older Adults through Safe Transitions initiative, we identified ways to improve the discharge process and improve care for heart failure patients:
- Metro Health improved patient education by providing nurses with a flip chart to review with patients prior to discharge, and by providing heart failure patients with a calendar and magnet to help them manage their condition at home
- All heart failure patients have a follow-up appointment scheduled with their physician and documented on their After Visit Summary (AVS) before they are discharged from the hospital
- All heart failure patients have an initial home care evaluation
- AVS documents for heart failure patients contain key elements of information that help patients and their primary care physicians manage heart failure from the physician’s office instead of the hospital
- For patients who are discharged to Skilled Nursing Facilities (SNFs), Metro Health improved communication between the Hospital and the SNFs to more clearly outline what follow-up care our patients need
- Metro Health improved communication in the Hospital by redesigning the daily hospitalist meeting to include cardiology and a discussion of what follow-up care each heart failure patient may need at discharge
- Two case managers were assigned to Level 5 to manage the discharge needs of all heart failure patients
- Metro Health redesigned the discharge summary so that outpatient physicians can more clearly understand what was done for each patient while he/she was in the hospital and what follow-up care the patient needs
- Metro Health calls all patients 24-48 hours after discharge to ensure they are doing well at home or in their SNF
While none of these steps on its own seems like a significant change, together they are greatly improving outcomes for Metro Health’s heart failure patients. As we continue to monitor how well these patients manage, we’ll continue making changes that will improve their lives and the lives of other heart failure patients.